Tag Archives: Substance Abuse & Addictions

Substance Abuse & Addictions

Grieving everyday losses

By Laurie Meyers April 24, 2019

As a society, we think we know what loss is: the death of a parent, partner or child; the destruction of a home through disaster; the shattering of finances through bankruptcy. These are tangible, recognized — sanctioned, if you will — losses. But counselors know that in reality, life brings myriad losses, many of which go unrecognized, unacknowledged and, most importantly, unmourned. The damage caused by these accumulated losses — sometimes referred to in the popular lexicon as “emotional baggage” — often brings clients to counselors’ doors wondering why they’re in so much pain.

In 1989, American Counseling Association member Kenneth Doka, who has written numerous books on grief and loss, established the phrase disenfranchised grief, which he defines as grief that is experienced by those who incur a loss that cannot be openly acknowledged, publicly mourned or socially supported. Disenfranchised grief may result from the loss of a relationship, the loss of identity or ability, pet loss, or even the loss of “giving up” an addiction.

“This unrecognized loss can be happening all around us but, because of the lack of acknowledgment and support, we wouldn’t know about it,” says ACA member Barbara Sheehan-Zeidler, a licensed professional counselor in Littleton, Colorado, whose practice specializes in grief and loss.

She gives the hypothetical example of a woman who is about to move to a thriving new town to start a higher paying job with great benefits. The woman has spent the past 20 years raising her family and creating a great life for her children, but now she is ready to move on. She is excited about entering this new phase in her life and meeting new people. At the same time, the woman is experiencing a lingering and persistent sense of sadness that she can’t explain.

What the woman is experiencing, Sheehan-Zeidler explains, is disenfranchised grief, which can affect clients in numerous ways:

  • Physically: Headaches, loss of appetite, insomnia, pain and other physical symptoms
  • Emotionally: Feelings of sadness, depression, anxiety or guilt
  • Cognitively: Obsessive thinking, inability to concentrate, distressing dreams
  • Behaviorally: Crying, avoiding others, withdrawing socially
  • Spiritually: Searching for meaning or pursuing changes in spiritual practice

In the example, the woman was not recognizing the losses of community, familiarity, social status and spiritual support from her local church that would come with moving, Sheehan-Zeidler explains. Once the woman actually identified and named those things as losses, the counselor was able to validate and explain her symptoms of insomnia, guilt, absent-mindedness, crying, indecisiveness, pervasive sadness and avoidance of social situations. This allowed the woman to grieve her losses and settle into her new life, Sheehan-Zeidler says.

“When we do not process unrecognized or disenfranchised losses, we run the risk of creating a narrative that is tainted with unprocessed feelings and unresolved grief,” she says. “Their Weltanschauung, a German word for worldview, is corrupted with an emotional burden that influences their beliefs and ability to connect. Consequently, they may be limited in projecting self-confidence needed to secure a new job or challenged to join a new social circle due to feelings of depression or unworthiness.” Unrecognized grief from the loss of a job, health or lifestyle can also cause secondary losses, such as damage to one’s self-esteem, a sense of shattered dreams, and lost community, she adds.

Sheehan-Zeidler helps clients process their grief through a variety of rituals. “I invite clients to create a special time, maybe 5 to 15 minutes daily, for the purpose of ‘being with’ their emotions and thoughts,” she says. “During this dedicated time, I suggest clients find a comfortable and private place to sit, journal their feelings and thoughts, light a candle, have soothing music, enjoy a cup of tea, and maybe have a special shawl or blanket to be used during these ‘time-to-mourn’ moments. Or maybe the client is more active, in which case I’d invite them to mindfully walk in a calming place where they can be with their thoughts and feelings as they reflect on their loss.

“The purpose of this time-to-mourn ritual is to create comfort around you and encourage the feelings to come forward in a planned way so we lead the dance with grief and mourning, and not the other way around. Additionally, as grief can come in unexpected waves, if we have a ritual in place, then we can put the ‘surprise’ grief aside, noting that we will visit with it the next time we are sitting or walking in our special place dedicated to honoring and processing the grief and mourning.”

Sheehan-Zeidler also recommends that clients drink plenty of water and get adequate sleep — taking naps if needed — as their minds and bodies process the loss. Finally, she reminds clients that their grieving process will include bad days, but also good ones.

Losing my addiction

“Put simply, disenfranchised grief is grief that is not acknowledged or valued by society,” says Julie Bates-Maves, an ACA member and a former addictions counselor. “Losses that are not seen as legitimate or worthy of our sadness or grief fit here.”

Addiction may be the king (or queen) of losses that are not typically viewed as legitimate or worthy. “Some people … don’t think that losing something ‘bad’ should hurt, but it does,” Bates-Maves says. “If we think about the functions of an addiction — that is, what they can provide for people — you start to see how hard they would be to give up.”

Bates-Maves notes all the ways in which addictions can fulfill people’s needs, albeit in unhealthy ways. “Addictive patterns often bring pain, but it’s a pain that’s familiar,” she notes. “They bring routine, even if it’s an unhealthy one. [It’s] the illusion of power and control over one’s body and mind: ‘I want to feel or think differently, and I know how to accomplish that.’”

Addiction can also provide companionship or escape from a sense of loneliness, whether through friends who also use, through distraction, through numbing (both physically and emotionally), or through the sense of energy and excitement that using substances can provide, Bates-Maves explains. “Losing any of that would be, at best, uncomfortable [and], at worst, unbearable,” she asserts.

“In my own clinical work and in speaking to other counseling professionals and clients, I have noted little discomfort or objection to exploring the negatives of an addiction with clients,” Bates-Maves says. “Notably, I have encountered hesitation or overt avoidance of the ‘positives’ of addiction, [such as] ‘don’t speak of the glory days’ or ‘don’t encourage clients to focus on what they miss; instead focus on what they have to look forward to in recovery.’ Consider this though — what if the ‘glory days’ are the only time the client felt powerful, or safe, or noticed, or admired, or skillful?”

When entering recovery, clients not only contend with the addition of a new set of behaviors, thoughts and feelings, but also an absence of “glory,” Bates-Maves continues. She believes that talking about the “positives” of addiction can help clients in recovery tackle challenges such as reestablishing a sense of their own identity, learning how to connect with others, and filling in any social skill deficits.

“Inviting reflection on the ‘glory’ of it all is a chance to observe a client reminisce about a time when they felt more worthy,” she explains. “If self-worth is centered on the addiction or a component of it, we need to know so we can help them redefine and reconstruct who they are, not just what they do. Losing an addiction is not simply losing a substance or behavior. It’s losing a way of surviving that our body and mind have become settled in. It can be a tremendous loss.”

As Bates-Maves points out, losses can occur anywhere along the addiction and recovery spectrum: prior to addiction; during addiction; during detoxification, treatment, initial, mid- or advanced recovery; prior to a lapse or relapse; and after a lapse or relapse. Some losses, such as a negative alteration in personal appearance or losing custody of children, may be the direct result of the person’s addiction. Other losses, such as the death of a parent, may happen separately from the person’s addiction but will still affect a client’s addiction or recovery, Bates-Maves emphasizes.

Other experiences common to people working to move from addiction to recovery include:

  • Loss of comfort: The person can no longer rely on his or her addictive pattern as a coping mechanism.
  • Loss of power: Choices are often restricted in recovery, and it’s not always OK to make a “bad” choice.
  • Loss of identity: The person may wrestle with the question, “If I’m not an addict, who am I?”
  • Loss of pain relief: The person may ask, “How am I supposed to manage my pain now? I don’t know any other ways that work as well as _________ does.”
  • Loss of perceived choice: Because substance use is no longer an option, the person has to find another way to live, cope and function.

“It can feel like the rug has been pulled out from under them, and some can flounder in the absence of the structure of an addiction,” Bates-Maves says.

“Also consider the more commonly talked about losses, like loss of lifestyle or [loss of] ‘using’ friends,” she adds. “While it may be healthy to move away from people who remain stuck in unhealthy patterns, it’s certainly not easy. As a counselor, I believe that people have a ton of worth, even in the presence of an addiction or negative behaviors. If I’m told to walk away from the positives of a relationship because there are also negative behaviors, I’d struggle. Clients deserve to struggle with that too. Health and happiness are not always the same thing. If I have the choice to be alone and healthy or to be in the company of others and unhealthy, I’d waiver — particularly if others forced me in one direction or another.

“I think it’s important that counselors really sit with what’s being asked of someone when they’re told they must now avoid people who are still using. Allow for the struggle and encourage clients to grieve the loss of good people who are still stuck. Don’t lose sight of the loss and grief there. Value what’s being lost or taken away instead of encouraging — or sometimes mandating — the death of a relationship. And talk about it. Balance is key. Talk about why some losses are needed, and validate that they’re painful. Allow the pain, allow the struggle, and help clients to cope with them as they move toward something different.”

Losses that are controllable — meaning that clients have some say over their occurrence — can actually foster hope in clients that there will be a chance for repair or course correction once they have adopted a new way of living, Bates-Maves says. Examples of losses that might be controllable include legal problems or convictions, family ruptures, loss of employment and financial problems.

However, even with new skills and hope, there is no guarantee that clients in recovery will be able to fix or recoup all that they have lost, she cautions. For that reason, counselors need to help these clients “sit with that and explore both options: How can I learn to be OK and heal if this is changed or fixed? And how can I learn to be OK and heal if this stays broken or less than I hope?”

“The key lesson there is that clients can reconstruct a meaningful life in recovery, even if some components never return to what they once were,” Bates-Maves says. “It’s about moving ahead and grieving what doesn’t move with you. Again, balance. Growth is often painful, and we want to value the pain and loss that come with growth. Knowing that some relationships have been damaged beyond repair might be very painful and a point of personal despair, but it can also be framed as a powerful motivator. We can mourn the past and work to repair the damage that’s done, and we can work to not repeat it. I think our main task as counselors is to help frame the pain as useful and informative. What people hurt about reveals what they value. It also reveals what they don’t want to repeat. Both elements are quite useful to a counselor in helping a client figure out where they want to go and how to start getting there.”

“I think the most important thing for counselors to remember is that change is really hard,” she emphasizes. “That may seem obvious, but consider how often we forget it. Sometimes clients are kicked out of treatment because they’ve lapsed or relapsed. Other times there are mandates about [whom] one can spend time with and [whom] one cannot, requirements for employment, etc.”

Continuing not to engage in addictive behavior, forging relationships with people who don’t use substances, and gaining and maintaining employment are all healthy goals. However, clients need to process many of their losses — particularly those connected to self-worth and self-efficacy — before it is possible for them to achieve those goals, Bates-Maves says.

“Give people credit for the pain that comes with change, and give them space to talk about it,” she urges. “Talk about how health and happiness aren’t the same thing [but] that the work of counseling is to make them closer. Talk about how in order to move forward, we often have to let go and how hard that is, even when we’re letting go of ‘bad’ things. Focus on where someone is and not only where we/they/you want them to be. If we want to help people move forward, we have to understand what’s keeping them where they are currently. But mostly, give people credit for the pain that comes with change, talk about it, and help them grieve.”

A question of identity

As a certified rehabilitation counselor and someone who sustained a spinal cord injury more than 30 years ago, ACA member Susan Stuntzner knows a lot about the losses and grief that come with disability. 

“At the time, I was paralyzed from the waist down, but within two months, I achieved some mobility and enough to walk with below-the-knee ankle-foot-orthotics [AFOs],” she recounts. “While learning to walk was a fantastic high point of the rehabilitation process, an equally important aspect was figuring out my new or different capabilities. More specifically, I learned I could not run, which is something I used to enjoy; lift more than 25-30 pounds; and that I had to push or pull things rather than lift as a means to move objects. I learned it was probably not a good idea to stand indefinitely and the importance of recognizing and honoring what my
body could do rather than expect me to do things in exactly the same way as I could before.”

Stuntzner also grappled with an issue that is particularly common among women with disabilities whose physical appearance is altered, either through injury or a disability present at birth: body image and attractiveness.

“Again, going back to my own experience, while muscles in my thighs worked, those below my knees did not. This meant my feet and ankles did not either,” she says. “Thus, there was a change in how I initially saw myself and my calves, as these did not have muscle return but they were an attached part of my body. Changing the way I viewed myself was difficult and a form of loss, as I was 19 years of age and highly conscious of fashion and, in particular, shoes. In short, I loved cool shoes and I still do. However, the partial paralysis below my knees meant I now had to wear AFOs and could no longer wear the stylish shoes I had so loved. While some of this may sound trivial, fashion and shoes — again, I was 19 years of age — was important to me, and this change represented a form of loss, along with the attention that my AFOs brought to the stranger passing by.”

“My own story is only one of many, as each person who lives with a disability — visible or invisible — has a story or set of experiences,” Stuntzner says. “For some, it may be cognitive changes [such as] memory, learning, recall, traumatic brain injury. For others, it may be health conditions [such as] irritable bowel syndrome, heart conditions [or] chronic obstructive pulmonary disease that disrupt daily activities and events. Other people live with sensory disabilities — loss of vision or hard of hearing. People who are hard of hearing but not deaf face challenges because people sometimes report not feeling as if they fit anywhere; they are not deaf, nor are they a part of the ‘hearing’ sector due to some of the limitations they experience.”

Regardless of a person’s specific set of circumstances, it is important that the person views themselves as a “whole” person, recognizes their assets and strengths, and builds upon those assets and strengths, Stuntzner says. Identifying one’s abilities, strengths and talents regardless of disability and functional limitations is a key part of what rehabilitation counselors help people do, she adds.

Counselors can help these clients grieve by listening and supporting them emotionally and psychologically as they work through the changes brought about by their disability, Stuntzner says. Counselors should understand that adjustment and grief are individualized processes and that two people with very similar conditions and functional changes may cope and adapt very differently, she notes. They also may require different therapeutic approaches to help them move forward. One size does not fit all based on disability type, Stuntzner emphasizes. It is important to view the person as a whole individual and to help people learn to see themselves as capable individuals comprising many different aspects and interests.

“Another key component of working through loss is helping people work through their negative thoughts and feelings, and experience successes, while living with a disability so they develop a strong internal locus of control and a sense that they can effect change in their life and create the life they seek,” Stuntzner says. “In short, it is about empowering people to discover who they are or who they can be in spite of the disability. As people become empowered, they learn to find their voice and own it and use it to help themselves and others. It is through this process that people oftentimes heal and learn to see the bright side of living with a disability.

“By bright side, I mean they learn to see the positive ways their life has changed or can change, and many find a higher purpose through the experience of living with a disability. However, this is a process, one that may begin with grief and loss, then morph into a personal and/or spiritual journey where people discover ways to grow and sometimes access their higher purpose or sense of self. It is on this journey that people find healing.”

Not just a pet

According to the American Veterinary Medical Association, at the end of 2016 (the latest year for which statistics were available), nearly 57 percent of American households had pets. Surveys have shown that the majority of people among that 57 percent also view their pets as part of the family. Yet many people do not regard the death of a pet as a “legitimate” loss. Indeed, those who have suffered the loss of a pet may not recognize their own grief, says licensed clinical professional counselor Cheryl Fisher, an ACA member whose counseling specialties include grief and loss.

In Fisher’s experience, it is not unusual for new clients to present with issues such as depression, anxiety or stress, and when talking about why they are seeking therapy, mention — almost as if it were a side note — “By the way, I just lost my cat.”

Fisher recalls a client who had come to her for grief counseling after the death of a relative. As Fisher listened, she realized that the client’s loss extended beyond that one death and that she was experiencing complicated grief.

The woman mentioned in passing that she rescued feral cats, two of which had died recently. These street felines were not easily domesticated, so the woman’s interactions with them had mainly been restricted to feeding them, Fisher notes. Yet the woman kept collecting them.

The client was very isolated. In fact, the recently deceased relative had been her only remaining family member. Except for the cats. As limited as her relationship was with them, the feral cats were her family, and she was grieving those losses as well.

“People are sheepish about sharing their grief, but our animals are the most vulnerable members of our families and also the most unconditional and accepting,” says Fisher, who shared the experience of losing her beloved dog Lily in her CT Online column, The Counseling Connoisseur (“Pet loss: Lessons in grief,” April 2017).

As she tells clients who are grieving (sheepishly or not), the relationships that people have with their pets — whether dogs, cats, fish or fowl — are strong not just emotionally but biochemically. In interacting with their pets, people feel a release of oxytocin, the hormone responsible for feelings of closeness and attachment.

Fisher also asks these clients to tell their “pet story.” She begins by asking how they met their pets. Fisher says the adoption or birthing story is very significant to the pet–human bond, and when clients start to recount it, they get very passionate as they open up to those memories.

“I always want to know the pet’s name, what kind [of animal it was], what the client liked to do with them and if they have pictures,” Fisher says. “It’s like traditional grief therapy — I’m helping them talk about their loved one.”

As clients talk, Fisher will say things that highlight the significance of their relationship with their pet. For example, she might say, “It sounds like Sadie stood right by you through the divorce.”

Fisher says she can almost see clients exhale: “You get it. I didn’t realize this was so important. She wasn’t just a cat!’”

Fisher also helps clients find ways to stay connected to their pet by giving examples of rituals that others have used. She urges clients to think about their relationship with their pet and the type of remembrance that would fit that bond.

For Fisher and her husband, it was taking Lily’s ashes to the beach where they and their goldendoodle had so often visited and played. “She loved the beach,” Fisher notes.

Some clients create scrapbooks with items such as their pet’s adoption papers and first pictures. Fisher included all the condolence cards she and her husband received in the wake of Lily’s death.

One of Fisher’s clients honored her cat, who loved to look out the window at birds, by constructing a special birdhouse that held pride of place next to the pet’s perch.

Fisher also mentions a video she saw at a conference on children and grief. It was called “Bridget’s Loss,” and in it, a little girl says goodbye to her fish in a “ritual flush.”

Fisher describes the scene: The mother, who filmed the video, asks her daughter if there is anything she wants to say before flushing the fish. The girl says, “Sammy, you were a good fish. You always did good fish things, and now you will be able to go with all the other fish, and I will see you in another time in heaven or wherever.”

The key to grieving pet loss is to have some kind of goodbye ritual, Fisher says, even if it is something completely private that involves only clients and their pet.

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

Webinars (aca.digitellinc.com/aca/pages/events)

  • “An Overview of Military Service Members and Their Families: How Mental Health Professionals Can Best Serve This Population” with John P. Duggan and Odis McKinzie (WEB17002)

Podcasts (aca.digitellinc.com/aca/store/5#cat14)

  • “When Grief Becomes Complicated” with Antoinetta Corvasce (ACA252)
  • “Love and Sex and Relationships” with Erica Goodstone (ACA231)
  • “Disability Awareness” with Robbin Miller (ACA196)
  • “Counseling Military Families” (ACA139)

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources/)

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Workforce projections show a coming surplus of school counselors, shortage of addictions counselors

By Bethany Bray January 28, 2019

According to the U.S. Health Resources and Services Administration (HRSA), there will be a shortage of addiction and mental health counselors and a surplus of school counselors and marriage and family therapists in the decade to come.

These predictions come from HRSA’s workforce projections, released recently for a variety of behavioral health professions, including professional counselors, through the year 2030.

Across the country, demand for addiction counselors is expected to increase by 21 percent through 2030, while the supply of these practitioners is expected to rise just six percent. For mental health counselors (defined as a practitioner “who work[s] with individuals and groups to deal with anxiety, depression, grief, stress, suicidal impulses and other mental and emotional health issues”), HRSA predicts that demand will grow by 18 percent while the supply of practitioners will grow by 13 percent.

In both cases, this would leave a deficit of many thousands of counselors across the United States.

“As indicated by the latest HRSA data, professional counselors who specialize in mental health and addictions are in high demand due to an ongoing, pervasive mental health workforce shortage and increased need, such as with the opioid epidemic,” says American Counseling Association President Simone Lambert. “As a profession, we must continue to advocate for access to mental health care in our schools and communities for clients of all ages and diverse backgrounds. In addition, we need to focus on creative solutions, such as telehealth, to service those in rural areas with limited mental health and addiction counselors. ACA continues to seek solutions toward licensure portability in the hopes that in the not-so-distant future professional counselors will be able to provide services across state lines or seamlessly relocate to assist struggling communities.”

On the flip side of the coin, HRSA reports that America is “producing a relatively large number of school counselors,” with a supply expected to increase by 101 percent through the next 11 years, far exceeding a demand growth of just three percent. Even if public schools across the country were to conform to the American School Counselor Association’s recommendation of one school counselor per 250 students, there would still be a surplus of school counselors in 2030, HRSA reports.

HRSA’s projected surplus of marriage and family therapists is not quite as extreme, with demand growing by 14 percent and workforce supply increasing by 41 percent through 2030.

HRSA released these behavioral health workforce predictions in December 2018.

This fall, the agency also released a state-by-state breakdown of supply and demand estimates for behavioral health jobs, including professional counselors, psychiatrists, social workers and other occupations through 2030.

Lambert, a licensed professional counselor and core counseling faculty member at Capella University, notes that the projected need for substance abuse and mental health counselors is reflected in the U.S. Department of Labor’s Occupational Outlook Handbook. The agency projects that employment of substance abuse, behavioral disorder and mental health counselors will grow 23 percent from 2016 to 2026, “much faster than the average for all occupations.”

 

 

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Find out more:

 

HRSA Behavioral Health Workforce Projections landing page

 

HRSA report: State-level Projections of Supply and Demand Behavioral Health Occupations: 2016-2030

 

U.S. Department of Labor Occupational Outlook Handbook for substance abuse, behavioral disorder and mental health counselors

 

 

 

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Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Standing in the shadow of addiction

By Lindsey Phillips October 30, 2018

Theresa Eschmann, a licensed professional counselor (LPC) and addiction family specialist in private practice in St. Louis, experienced firsthand the power of denial in adult children of parents with alcohol use disorders. All her life, Eschmann had witnessed her mother struggle with this disorder, yet upon finding her mother dead with a bottle of alcohol in her hand, Eschmann’s first response was denial. She couldn’t believe that her mother’s alcohol use disorder had caused her death, initially insisting that someone must have poisoned her.

“I … took a chemical dependency proficiency certification to try to get some understanding of what killed her because it couldn’t have just been alcohol,” Eschmann says, explaining her thinking at the time. “Alcohol made you sick. It made you have delirium tremens. It made you see things. But it couldn’t have killed you.”

Denial is often a strong coping mechanism for adult children of parents with alcohol use disorders, says Lisa Kruger, an LPC and psychotherapist and the owner of Stepping Stone Psychotherapy in the Washington, D.C., metro area. “They have to deny any feelings of sadness or anger that they might have in order to survive,” she says.

This denial extends to adult children’s own potential struggles with substance use disorders. Keith Klostermann, an assistant professor in the Department of Counseling and Clinical Psychology and the director of clinical training for the marriage and family therapy program at Medaille College, had a female client whose father chronically abused alcohol, and her own drinking often led to fights with her boyfriend. One of these drunken fights resulted in her breaking her foot. Even so, she maintained a permissive attitude toward drinking and brushed it off as a recreational activity.

The client was firmly in denial and not yet ready to address either her experience of growing up around substance abuse issues or her own drinking habits, says Klostermann, a licensed marriage and family therapist and licensed mental health counselor who maintains an active practice in New York. Counselors may be eager to push clients to explore these issues, but Klostermann warns that discussing the implications of this childhood experience before clients are ready is a recipe for disaster. Taking that approach may lead to problems establishing a therapeutic alliance or cause clients to end counseling prematurely, he explains. Instead, he advises, counselors can help clients connect the dots and arrive at an understanding that their behavior makes sense based on their experiences growing up.

Asking the right questions

Being an adult child of a parent with a substance use disorder is not uncommon. According to the National Association for Children of Addiction, 1 in 4 children in the United States (or approximately 18.25 million children) live in a family with a parent who is addicted to drugs or alcohol. Yet, Eschmann, a certified master addiction counselor and a member of the American Counseling Association, says it’s her sense that asking whether clients grew up in homes where addiction was present is often skipped over in clinical assessments.

In addition, because these individuals have frequently learned to minimize, discount or deny the implications of growing up in a home with substance abuse, they aren’t particularly likely to seek counseling for those issues.

Being a child of a parent who abused substances “may be the elephant in the room, but that may not be what brings them in. They may not recognize it,” says Klostermann, an ACA member. “The stuff that happens to us when we were younger, a lot of times we carry with us, [but] we don’t even realize why we do the stuff we do. We just sort of do it out of inertia.”

Klostermann and Kruger say that many of their clients present with relationship problems, anxiety, stress, depression and substance use. Often, the counselors note, these issues result from growing up with a parent who had a substance use disorder.

The environment of walking on eggshells around a parent who is under the influence of a substance creates and breeds anxiety for the child, Klostermann explains. When the child becomes an adult and engages in stressful situations in college (e.g., exams) or at work (e.g., deadlines), the person’s anxiety can snowball, he adds. Likewise, they may struggle with adversity and withdraw socially because they find it difficult to navigate relationships. This isolation can lead to depression, which is a real challenge, Klostermann says.

Counselors can look for possible warning signs that their adult clients were exposed to substance abuse issues in the home as children, Klostermann says. For instance, clients might engage in avoidant strategies (e.g., using alcohol as a way to cope with stress) or have a permissive attitude about substance use (e.g., “I don’t drink much. I only have a 12-pack a day.”).

Kruger, an ACA member who specializes in the areas of depression, anxiety, posttraumatic stress disorder, trauma and addiction, had a male client who came to see her for help with relationship issues and high anxiety. In his intake paperwork, the client wrote that he drank nightly, so she asked him how many drinks he had in a week. “It was 50 to 60 a week,” he replied, “but now it’s only 20 or 30.” This response was a big red flag, yet he didn’t realize that his drinking was a problem, she says.

To help clients recognize unhealthy behaviors, Kruger often uses motivational interviewing techniques. For example, with this client, a counselor might ask, “How is drinking 20 or 30 drinks a week working out for you?”

If counselors see potential warning signs, Klostermann advises asking questions about current substance use patterns, previous substance use, parental substance use and family attitudes around drinking. For example, counselors might ask the following questions: What was it like growing up in your home? What does drinking a lot or having a good time mean to you? What does that look like? What are the holidays and celebrations like in your family? What is a typical family dinner or birthday party like?

“Substance use is built around so many family functions and gatherings and celebrations,” Klostermann says. So, if a client comments, “My parents liked to party,” counselors could follow up by asking the client to explain what that means and what the implications are for the client’s life (e.g., increased violence after a parent drank, embarrassment when a parent became intoxicated at a social event). Klostermann explains that these types of questions help clinicians gain a better understanding of not just the acute nature of growing up in an environment with substance abuse but also the context of it — for instance, whether parental drug use led to a more permissive attitude at home or whether the child adopted unhealthy coping strategies.

In addition, adult children often find it easier to talk about others rather than themselves, Klostermann says. By asking these types of nonjudgmental questions (e.g., “Did drinking like that seem to work out for your mom?”), counselors can help clients create insight and awareness by changing the frame of reference, he explains. This technique helps clients gain an understanding about not only the severity of their parents’ alcohol or substance use but also the emotional implications of that behavior, he adds.

After counselors establish that awareness, Klostermann says, they can connect it to the client’s present situation (e.g., “Does drinking affect your relationships or grades?”). He suggests that counselors could also try to educate clients by saying something along the following lines: “Given what you described about your [parent’s] history, it’s not uncommon for people that grow up in these homes to sometimes exhibit certain behaviors. Sounds like that might be happening for you.”

Counselors are “planting the seed [and] leaving the door open but also helping [clients] to connect the dots and understand this is what’s going on and here’s why,” he explains.

In addition to asking about clients’ personal and family substance use histories, Kruger often focuses her questions on clients’ relationships with their parents. These questions can help bring out emotions such as shame, guilt or anxiety that stem from being a child of a parent with a substance use disorder, she says.

Emotional and attachment wounds

“Adult children of alcoholics … have difficulty identifying and expressing emotions,” Kruger explains, “because when they were kids, they had to set aside their own emotions — maybe they had to care for their parents. … They didn’t understand what their emotions were because what they saw in their parents’ relationship was inconsistent presentation or organization of emotions between them and maybe even between the parent and child too.”

To help clients who are having difficulty expressing their emotions, Kruger provides a sheet that shows 50 visual representations of emotions and asks clients to name the emotions that describe how they are feeling. She says this activity, which she refers to as an “emotional cheat sheet,” is “a good springboard … for clients who really don’t have the language [for their emotions].”

Kruger and Eschmann find that codependency is another common issue for adult children of parents with alcohol use disorders. Because these adult children grow up being sensitive to the needs of their parents — even to the point of ignoring their own needs — they often engage in approval seeking, which leads to codependency, Kruger explains. This need for approval and to avoid conflict can result in these individuals seeking acceptance from others who do not treat them well, which causes lower self-esteem, she says.

Often, clients who are codependent will assume they are OK because they are not the ones causing problems, Eschmann observes. She questions clients on codependent behavior by asking about their controlling behaviors, approval-seeking behaviors, anxiety, and distortion around intimacy and separation.

For Kruger, it all comes back to attachment — how bonds are created and broken. Parents who struggle with alcohol use disorders are typically inconsistent in their parenting and in their show of emotion toward their children. As she points out, this can create attachment wounds and be stressful for children growing up under these circumstances. Children may be doubly affected because they still depend on parents for care and for getting many of their emotional needs met. At the same time, these children often aren’t in a position to fight or to flee elsewhere, she adds.

Counselors can help adult clients gain awareness of how their current relationship patterns are affected by their childhood experiences, Kruger says. One technique she finds helpful involves taking the client’s experiences and imagining how those experiences would be perceived on The Brady Bunch. As a member of The Brady Bunch family, Kruger explains, the client would notice instantly if a partner or spouse were abusive because of the contrast with the sitcom family. However, growing up in a stressful environment with one or both parents suffering from an alcohol use disorder tends to distort a person’s perceptions of what is “normal” or acceptable.

For example, having a parent who drank and was inconsistently present when the client was a child would affect the client’s ability to evaluate his or her current relationships. If the client has a partner who sometimes withholds affection or emotion, is manipulative and comes around only when he or she wants something, the client won’t necessarily notice any red flags because those are the circumstances and relationship patterns the client knows from growing up, Kruger explains.

Kruger also gives short attachment assessments and finds that these clients often present with anxious attachments. “In relationships, [they cater] to the other person because that attachment anxiety comes up and that need for approval keeps them in relationships” — including bad ones, she says.

To help clients see the connection between their view of themselves and their relationships with others, Kruger will have clients write out how they view themselves, how they view other people and how they view the world. Then, they will discuss how these views are created, how clients are perpetuating these views and how they would like to see themselves in relationships.

The exercise is particularly helpful for clients who find themselves in toxic relationships, Kruger adds. “It’s really rare [for] somebody in a toxic relationship [who is] being manipulated to say, ‘I see myself in high regard, and I think I’m great.’ It’s usually the opposite,” she says.

Making meaning of conflicted feelings

Another crucial part of adult children’s recovery is sorting through their conflicted feelings of love, disappointment, anger and shame. In fact, both Eschmann and Kruger find that shame and guilt are common presenting issues.

Children often feel that a parent’s situation is their fault, and they find it difficult to process these multilayered emotions, Kruger notes. They simultaneously feel disappointment in and love for their parent. For adult children, processing and making sense of these feelings is a substantial part of recovery, she explains. Counselors should acknowledge that shame piece and how clients have “put that burden on themselves and carried that burden with them throughout adulthood,” Kruger advises. 

“Shames translates to I am bad,” Kruger points out. “Even if [clients] don’t present it on the outside, they’re usually coming in with some pretty damaged self-esteem and are already judging themselves.” In part for that reason, she emphasizes the importance of creating a nonjudgmental atmosphere in counseling.

When self-esteem, thoughts and feelings are involved, Kruger uses cognitive behavior therapy techniques. She says she has experienced a good deal of success with an exercise that blends cognitive restructuring and emotion identification. In the exercise, clients look at a triggering event and then identify their negative self-talk and automatic thought, the feeling that this thought creates, evidence to strengthen this thought, evidence against this thought and a new thought that they can believe.

The exercise allows clients to recognize their negative self-talk and its consequences and enables them to reconfigure these self-demeaning thoughts in a way that is believable to them, Kruger explains. For example, clients might think that they are “bad” and list all of the evidence they have for that thought. Next, they could counter that thought with the fact that they recently got a raise at work. Finally, they could create a new thought that sometimes they do good things, Kruger says.

“These clients need validation,” Eschmann emphasizes. “They didn’t get it growing up.” Instead, she explains, the parent who was abusing alcohol or other substances has often discounted the adult child’s feelings and experiences.

Klostermann also stresses the importance of normalizing these clients’ emotions and experiences. These clients may not realize — or, in some cases, perhaps don’t want to realize — the impact on them of their parents’ drug or alcohol use, he says. He notes how difficult it can be for clients to verbalize that their parents had or have a drinking problem, especially if they maintain a glorified version of their parents. For this reason, counselors need to help clients understand that it is possible for them to love their parents while still recognizing that their parents made mistakes.

Kathleen Brown-Rice, department chair and associate professor in the Department of Counselor Education at Sam Houston State University, agrees. Counselors must keep in mind that the family member is someone whom the client still loves and cares about, she says. Counselors can give clients the “space to say that you can love somebody and also be disappointed by their behaviors. You can love someone, and they can love you, and they can still hurt you,” she says. “[It’s] helpful for clients to understand that it’s more complicated than just [their parents are] bad or they don’t love [them].”

Eschmann helps clients focus on unresolved grief, which is common for adult children who grew up with parental substance abuse. Adult children are often hesitant to admit that their mom left them alone all night with a stranger or that their father came home drunk and had violent arguments with their mother, Eschmann says. They might not want to admit that these past events are why they get triggered today during certain situations.

“[Clients] have to accuse before [they] can excuse,” Eschmann asserts. “They have to go back and [ask], ‘What happened to me?’ This isn’t about [the parents] anymore. It’s about [the client].” If clients become more aware of what happened to them and what kind of environment they lived in that made them fearful and anxious today, then they can start healing, she adds. 

Mindful resilience 

Adult children who grew up in the same environment with substance abuse can respond very differently. One person may be angry, whereas another may be empathetic, and still another may end up also struggling with a substance use disorder. This raises the question of why some adult children of parents with alcohol use disorders are more resilient than others.

Resilience is “critical in terms of shaping kids’ development as they transcend into adulthood in terms of the choices that they make and the way that they deal with stress and conflict,” Klostermann points out. Based on his clinical experience, Klostermann suggests that having other healthy outlets (e.g., extracurricular activities such as sports, positive role models such as grandparents) and an ability to contextualize what is happening help to foster resilience.

Brown-Rice, an LPC and a member of ACA, acknowledges that there is more than simple genetics at play with resiliency. “Resiliency is not a moral characteristic. It’s a function of our brain,” she says. It’s “how our brain controls for those genetics … how that resiliency comes in and how we support that.”

Recently, she, along with Gina Forster (a lecturer in the Department of Anatomy at the University of Otago) and several other colleagues, conducted a study funded partly by a grant from the Center for Brain and Behavior Research at the University of South Dakota on college students who had similar experiences of being adult children of parents with substance use disorders. The participants identified as either engaging in risky substance use (the vulnerable group) or not engaging in risky substance use (the resilient group).

“Overall, their experience being raised by a parent who met the criteria for having a substance use disorder appeared similar,” says Brown-Rice, who presented the findings at the ACA 2017 Conference in San Francisco. However, “vulnerable individuals had lower scholastic performance … [and] reported poor overall psychological, physical and social health and more polysubstance use.”

The study also revealed another difference: The vulnerable group had a short allele of the serotonin transporter gene, which meant they were more likely to react to stressful events. “[This group] had a reduced uptake of their serotonin, which can increase depression and stressful life events,” explains Brown-Rice, associate editor of the Journal of Addictions & Offender Counseling.

Brown-Rice and the other researchers also measured brain activity while the participants viewed positive images (e.g., a cuddly bear), negative images (e.g., a crying baby) and neutral images (e.g., a chair). They found that the vulnerable group had altered brain activity when processing negative images. This group recognized the negative image but refused to store it, Brown-Rice explains.

Brown-Rice hypothesizes that this refusal to store negative images is an important factor in resiliency levels. To illustrate, imagine that you are walking outside and see a stick. Initially, your brain may think that the stick is a snake, so you jump back. As Brown-Rice explains, when you first see the stick, the amygdala activates and warns you because it looks like something that the brain remembers could hurt you. But after taking a closer look (i.e., storing the image), you realize it is just a stick, so you relax.

Resiliency depends on our ability to realize that the stick is not a snake. Some people, however, may be more likely because of brain functioning or genetic variations to see the stick and just react by running, Brown-Rice says. Thus, counselors can help certain clients by nurturing the parts of the brain that activate during stressful situations, she explains.

Brown-Rice incorporates this research into her clinical practice. She tells her clients that they have a resilient part of the brain — the prefrontal cortex — and that in session, they can work on controlling their brain and building their optimism and resiliency. She suggests that counselors use mindfulness techniques, such as guiding clients in breathing exercises and finding a safe place to go when triggered, because mindfulness is effective in calming the amygdala, which activates during stressful events.

Consistency also helps promote clients’ resiliency, Brown-Rice notes. If counselors are inconsistent, she says, that will put clients on edge.

Klostermann agrees. He finds that having a clear agenda helps to create a sense of safety and build rapport with clients. He informs them about his clinical approach and what to expect during the session and tells them there is no assumption on his part that they will schedule another appointment.

Kruger recommends using clients’ resiliency to help strengthen their internal sense of self. After all, she points out, adult children of parents with alcohol use disorders have already developed survival strategies, such as caring for siblings in areas in which the parent was lacking.

Instead of simply telling clients that they have strengths, Kruger uses motivational interviewing, which allows clients to identify and recognize their strengths themselves. For example, rather than telling a client, “You seem to be good at your job,” she might ask, “In what ways are you praised at your job?” This question helps clients reach the conclusion themselves, which builds their internal positive regard.

One more piece of advice for working with adult children of parents with substance use disorders: Counselors shouldn’t be afraid to change their approach if it’s not working. For example, Brown-Rice says, research has shown that people who have a short allele for serotonin may be resistant to cognitive behavior treatment. “If clients are not responding, we have to think maybe we need to change,” she says. “Maybe we need to move. Maybe we need to [incorporate] some of these mindfulness techniques. Maybe we need to do something else.”

Sometimes, it may be the counselor, not the client, who is being resistant, she stresses.

Halting the domino effect

The desire to get treatment for someone with a substance use disorder often overshadows the way that addiction affects the person’s family and others who care about the person. It shouldn’t.

In her educational video on addiction in the family, Claudia Black, an expert in addiction, highlights a child’s drawing of his experience living in a home where substance abuse is present. The child draws images of dominoes and writes, “Alcohol and drugs are like dominoes. They knock down the person, who knocks down everyone, including themselves.” The child’s words illustrate the way that addiction permeates and affects the entire family, not just the person with the substance use disorder.

For the first two years after her mother died from alcohol-related causes, Eschmann found herself crying repeatedly. Her grief and denial led her to learn more about chemical dependency, addiction and adult children of parents with alcohol use disorders. Counselors need to understand that the family has an emotional illness as well, Eschmann emphasizes. This illness is just as progressive as what the person with the substance use disorder is facing, she adds.

Brown-Rice reminds clients that they are not responsible for their substance use issues, but they are responsible for how they respond to these issues. For adult children of parents with substance use disorders, this means learning how their childhood experiences affect their current behaviors and choices.

Adult children of parents with substance use issues often feel isolated. Support groups such as Al-Anon and Adult Children of Alcoholics are helpful because they provide opportunities for people with similar experiences to share their stories and come to the realization that they’re not alone, Kruger says.

Counselors should also help clients understand that their parents’ substance use is not their shame to carry and substance abuse is not a legacy that they have to repeat, Brown-Rice says. Then, clients will realize that choosing a different path doesn’t mean that they are being disrespectful or dishonoring their parents, she explains.

The hope is that this different path will stop the domino effect of addiction, shame, depression and pain.

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at consulting@lindseynphillips.com or through her website at lindseynphillips.com.

Letters to the editorct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Group counseling with clients receiving medication-assisted treatment for substance use disorders

By Stephanie Maccombs September 6, 2018

Holistic care, or the integration of primary and behavioral health care along with other health care services, is becoming more common. In my experience as a mental health and chemical dependency counselor in an integrated care site, I have come to value the benefits that such wraparound services offer.

I now have the opportunity to consult with primary care providers, medication-assisted treatment providers, dentists, early childhood behavioral health providers and our county’s Women, Infants and Children team about their perspectives and hopes for clients. Every client has a treatment team, and each team member is only a few feet from my office door. I quickly realized the significant positive impact that close-quarters interdisciplinary collaboration has for many clients, and particularly those receiving medication-assisted treatment (MAT) and counseling services for substance use disorders.

MAT is a treatment model that lends itself to the integrated care setting. As described by the Substance Abuse and Mental Health Services Administration (SAMHSA), MAT is the use of prescribed medications with concurrent counseling and behavioral therapies to treat substance use disorders. MAT is used in the treatment of opioid, alcohol and tobacco use disorders. The medications, which are approved by the Food and Drug Administration, normalize brain chemistry to relieve withdrawal symptoms and reduce cravings. MAT is not the substitution of one drug for another. When medications in MAT are used appropriately, they have no adverse effects on a person’s mental or physical functioning.

Medications used in MAT for alcohol use disorder include disulfiram, acamprosate and naltrexone. Those used for tobacco use disorders include bupropion, varenicline and over-the-counter nicotine replacement therapies. Medications used in MAT for opioid use disorders include methadone, buprenorphine and naltrexone — each of which must be dispensed through a SAMHSA-certified provider. Naltrexone is the only medication of the three that does not have the potential to be abused. Federal law mandates that those receiving MAT for opioid use disorder also receive concurrent counseling.

Embracing the advantages of integrated care

The combination of medication and therapy offers a holistic approach to treatment that is easily implemented in integrated care settings. The hope offered by the integration of services is embodied in an extraordinary case involving one of my clients who relapsed and arrived to counseling intoxicated, holding their chest. I was able to immediately consult with the client’s MAT provider, who ruled out the physical causes of chest pain after performing an electrocardiogram. Within 30 minutes, I was able to proceed with de-escalation of the client’s panic attack. The MAT provider educated the client on the next steps for care and on the dangers of using substances while taking MAT medications.

In a nonintegrated site, my only recourse would have been calling an ambulance for the client and a long wait at the hospital emergency room — and possibly a client who discontinued services. It is heartening when I can instead walk a client with symptoms of withdrawal across the hallway to the MAT provider or primary care provider, who can in turn offer targeted expert medical advice and medications to alleviate the symptoms.

Despite the substantial advantages that integrated care offers, however, most mental health and chemical dependency counselors are not adequately trained to provide effective counseling in integrated care settings for substance use disorders. In my experience, clients have better outcomes when receiving counseling services in conjunction with MAT. MAT alone can be effective, but the underlying thoughts and emotions that perpetuate use are not addressed unless concurrent counseling services are offered.

According to SAMHSA’s Treatment Improvement Protocol (TIP) No. 43, counseling for clients in MAT programs:

  • Provides support and guidance
  • Assists with compliance in using medications in MAT appropriately
  • Offers the opportunity to identify additional areas of need
  • May assist with retention in MAT programs
  • Offers motivation to clients

Although individual counseling is valuable, I am focusing on group counseling in this article because it offers similar benefits to individual counseling and is typically more cost-effective. In addition, TIP No. 43 notes that group counseling in MAT programs reduces feelings of isolation, involves feedback and accountability from peers, and enhances social skills training.

Resources for group counseling with MAT clients, or group counseling in integrated care settings, may not be easily accessible to many counselors-in-training or to practicing counselors. My goal is to share tips and resources with mental health and chemical dependency counselors that may be helpful in enhancing group counseling services for clients receiving MAT in integrated care settings. These tips and resources may also be useful to those providing group counseling services to MAT clients in settings that do not offer integrated care.

Tips and resources

1) Holistic education: MAT and integrated care are relatively new concepts for counselors, and we are still adapting. If it is new for us, it is new for our clients too. In the initial sessions of psychoeducational or process groups, the inclusion of education about MAT, the benefits of counseling in conjunction with MAT, and treatment in integrated care settings is essential.

Having access to a range of service providers is a benefit that clients should understand and utilize. Treatment team members can speak to the group about their role in client care and how their role may relate to the counseling group. For example, a dentist might help with appearance and self-esteem issues; an early childhood care provider might help the children of clients process situations arising from parental drug use; a primary care or MAT provider might link the client with hepatitis C treatment in addition to MAT. Such education can answer many questions that the group may have and help clients benefit from quality holistic care.

2) Dual licensure and continuing education: Many chemical dependency counselors refer out to mental health counselors and vice versa. In integrated care, it is ideal for counselors to be dually licensed. Dual licensure and training can assist counselors in identifying and addressing a variety of dynamics that may arise in group counseling with MAT clients.

For example, one client might have major depressive disorder and be using MAT for alcohol recovery, whereas another client might have symptoms of mania and be receiving MAT for opioid recovery. The way that counselors assist these clients may differ based on their knowledge of mental health diagnoses and the substance being used. Furthermore, counselors who are knowledgeable about these differing yet comorbid disorders will be better equipped to provide education to the group about the individualized and shared experiences of each member in recovery.

Some states have a combined mental health and chemical dependency counseling licensure board, whereas others have separate licensing boards. For more information about licensure, contact your state boards. If dual licensure is not plausible or desirable, I strongly recommended seeking continuing education in both mental health and chemical dependency counseling, as well as their relation to MAT.

3) Cognitive behavior therapy (CBT) and solution-focused brief therapy (SFBT) techniques: According to SAMHSA’s webpage about medication and counseling treatment, by definition, MAT includes counseling and behavioral strategies. The combination of MAT with these strategies can successfully treat substance use disorders.

One of SAMHSA’s recommended therapies is CBT, an evidence-based practice that has been shown time and time again to be effective in the treatment of substance use disorders. In an extensive review of the literature about the efficacy of using CBT for substance use disorders, R. Kathryn McHugh, Bridget A. Hearon and Michael W. Otto (2010) outlined a variety of interventions shown to be effective in addressing substance use disorders in both individual and group counseling. Those interventions included motivational interviewing, contingency management, relapse prevention interventions and combined treatment strategies.

Combined treatment refers to the use of CBT alongside pharmacotherapy, which includes MAT. Although some studies the authors reviewed indicated that MAT alone could be effective in treating substance use disorders, others demonstrated that combined treatment was most effective. Given SAMHSA’s recommendation, the literature review and my own personal experience, I believe that CBT may best benefit a group of MAT clients with substance use disorders in an integrated care setting.

Although CBT is suitable, I have learned that integrated care sites are much more fast-paced than the typical behavioral health counseling agency. Primary care and MAT appointments are as short as 15 minutes. In my work with our on-site behavioral health consultant, I noticed her quick and effective use of SFBT with individual clients. Although there is some research discussing the use and efficacy of SFBT in the treatment of substance use disorders, there is little information about using SFBT in groups with MAT clients in integrated care. This is a much-needed area for future research.

4) SAMHSA: SAMHSA has been mentioned various times throughout this article. That is a tribute to the value I place on the agency’s importance and usefulness. SAMHSA, in my opinion, is the best resource for exploring ways to enhance groups for clients receiving MAT. SAMHSA offers educational resources about a variety of substance use disorders; forms of MAT for different substances; comorbidities; and evidence-based behavioral health practices. SAMHSA is up to date, provides a variety of free resources for counselors and other professionals, and also has information about integrated care for professionals and clients.

According to SAMHSA’s TIP No. 43, groups commonly used with MAT clients include psychoeducational, skill development, cognitive behavioral and support groups. Suggested topics for individual counseling with MAT clients, which easily can be translated to group format, include feelings about coping with cravings and a changing lifestyle; how to identify and manage emergencies; creating reasonable goals; reviewing goal progress; processing legal concerns and how to report a problem; and exploring family concerns. Visit SAMHSA’s website (samhsa.gov) to enter a world of helpful information and resources for both personal professional development and client development.

5) Professional counseling organizations: Whereas SAMHSA offers information about substance use disorders, comorbidities, MAT, and individual and group counseling, the counseling profession’s codes of ethics and practice documents are crucial to the ethical provision of group counseling in this challenging field. Among the resources to consider are the 2014 ACA Code of Ethics, the Association for Specialists in Group Work (ASGW) Best Practice Guidelines (which clarify application of the ACA Code of Ethics to the field of group work) and the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling’s (ALGBTIC’s) competencies for providing group counseling to LGBT clients. ASGW also has practical resources to augment your group counseling skills through its Group Work Experts Share Their Favorite Activities series. Combining these resources with information acquired from SAMHSA and the tips in this article should prove helpful in designing and running effective groups for clients in MAT in integrated care settings.

Conclusion

As integrated care becomes more widespread, counselors must adapt their practice of counseling to the environment and to the full range of client needs. It is a counselor’s duty to utilize the benefits that integrated care has to offer, such as immediate and continual collaboration with treatment team members.

For clients in MAT, group counseling in integrated care can provide a multitude of benefits, including the opportunity to learn from each treatment team member, the opportunity to build community in the journey to recovery and accountability. To enhance group counseling in these settings, counselors might consider:

  • Including education from each service provider in the early stages of the group
  • Seeking dual licensure or relevant continuing education opportunities
  • Implementing theories that are suitable for the client issue and the setting
  • Using resources made available by SAMHSA and professional counseling organization such as ACA, ASGW and ALGBTIC

Implementing these tips and resources will result in a fresh and efficient group counseling experience for clients in MAT in integrated care settings.

 

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Stephanie Maccombs is a second-year doctoral student in the counselor education and supervision program at Ohio University. She is a licensed professional counselor and chemical dependency counselor assistant in Ohio. She has worked as a home-based addiction counselor and currently works in a federally qualified health center providing mental health and chemical dependency counseling services to adults participating in medication-assisted treatment. Contact her at sm846811@ohio.edu.

 

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Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Spinoza was right: Four steps to recovery from addiction

By James Rose August 21, 2018

The 17th-century Dutch philosopher Benedict Spinoza wrote that “when a man is a prey to his emotions, he is not his own master, but lies at the mercy of fortune.” He named this condition “human bondage.”

In my view, there is no greater form of human bondage among us now than drug addiction. Addiction is a form of self-imposed bondage that binds people as firmly as if they were held in chains. People who are addicted are being held in a form of bondage that is rooted in their own emotions.

In my three years of working with people in recovery from addiction, I have seen a clear pattern emerge. Individuals who begin recovery by detoxifying from their drug of choice soon feel a rush of hard emotions. These hard emotions are the ones they have been suppressing with their drug use.

From there, successful recovery follows a few distinct steps:

1) Patients name the emotions they are feeling.

2) They identify the story they have been telling themselves about the people, events or circumstances that are at the root of those hard emotions.

3) They examine the meaning of the story they have been telling themselves and consciously challenge that meaning.

4) They find a way to change the meaning of their story.

Because emotions flow from the stories we tell ourselves, patients in addiction recovery can then begin to change the emotions they feel, including the hard emotions that led to their drug use.

Let’s examine these four steps to recovery in detail.

1) Identify the hard emotions that arise. People vary significantly in their ability to discuss emotions. In general, women tend to be better at expressing their emotions than are men. Among people who abuse substances, both men and women typically struggle with expressing emotions. Not knowing how to handle strong emotions, and needing to numb them out, is often at the root of their use.

I often begin group counseling sessions by asking patients to name various emotions. It is a warm-up exercise to get them thinking about the range of emotions that exist and whether they are feeling them at that moment. Among the emotions frequently listed are loneliness, sadness, abandonment, depression, anger and hurt. Often, I will fill a chalkboard with their emotion words and then ask the participants to pick out a few words that apply to them. By giving patients a broad panoply of emotion words to choose from, they often find it easier to name their own emotions.

2) Identify the people, events or circumstances from which those hard feelings arose. For one young man, it was seeing his father, whom he considered his “rock,” suffer from diabetes and have his foot and part of his leg amputated. This was followed two years later by his father’s death. For a young woman, it was the death of her mother and the simultaneous abandonment by her boyfriend. For another young man, it was the emotional coldness of his father, which compelled him to threaten to commit suicide to get his father’s attention.

A sense of abandonment — and, in particular, abandonment in one form or another by a parent — plays a large part in many people’s addictions. A parent might be physically absent, either through death or divorce, or a parent might be physically present but emotionally absent. This can be the result of a parent who is simply emotionally distant by nature or a parent who is emotionally absent because they are involved in some form of addiction to drugs, alcohol, work, sex, gambling, pornography or other things.

Children by nature model themselves after their parents. Sometimes children are unaware of this modeling behavior. One client hated that his father struggled with alcoholism. So much so that this client had promised himself he would never drink alcohol, and he kept his promise. Instead, he used heroin. He had simply replaced one addiction with another, becoming as emotionally unavailable to others as his father had been to him. One common element among all addictions is that they make a person emotionally unavailable to others around them.

Sometimes I use the analogy of fun-house mirrors — those mirrors they sometimes have at carnivals that distort people’s images. As children, we try to get a clear picture of who we are by the image we see reflected in the eyes of our parents. If a child is fortunate enough to have mature, healthy parents, that child is more likely to gain a reasonably accurate self-image from their parents and have a secure emotional foundation from which to face life.

But if a child’s parents are unhealthy or immature, then the self-image the child receives from those parents is more likely to be distorted or flawed. These children may go through life with the unsettled sense that there is something wrong with them. The grown child then lacks a basis for determining what his or her self-image should be.

That sense of not being able to see oneself clearly can create a lasting pain in a child’s heart, and addictive behaviors are more likely to develop in an effort to numb out that pain. As counselors, our work can involve “reparenting” our clients by providing a clear self-reflection of who they truly are — an image these clients might never have received from their actual parents.

There is also a hidden stigma involved in situations in which children have the opportunity to become better than their parents. Sometimes this stigma is called invisible loyalty. For example, if a child comes from a family where drinking is normal behavior, the child risks breaking a family norm — and thus becoming “better” than his or her parents — by not drinking. That is a step toward independence that not everyone is willing to take.

3) Challenge the story you are telling yourself. Often, the event or circumstance involved in the triggering event creates a terrible blow to the person’s self-esteem. For example, the client whose father walked out on the family when the client was 5 was taught in the most unmistakable terms that he was worthless. The woman whose mother died and whose boyfriend left her shortly thereafter simultaneously suffered both grief and abandonment — abandonment at a moment in her life when she most needed someone she could turn to and trust to help her deal with her grief. The young man who lost his father to diabetes felt cast adrift without the man who had represented stability in his life.

Our emotions follow our narrative. If the stories we tell ourselves are ones of loss, abandonment and aimlessness, our feelings will be ones of worthlessness. It is that feeling of worthlessness at the core of our being that is often at the root of addiction. Addiction is a way of trying to numb out those unbearable feelings. If our narrative tells us that all is lost, then there is nothing much to do but to numb out our pain and drag ourselves through life as best we can.

Our feelings are predictions of what to expect, based on our past experience. If our past experience has been full of sorrow and loss, we will come to expect more sorrow and loss in our lives. We will approach the potential of something joyful happening in our lives with dread, lacing it with the expectation that, sooner or later, things will turn out badly. If close relationships turn into abandonment and loss, we might create self-fulfilling expectations by not entering into new relationships with openness.

And yet, it is human nature to want to have close relationships. One young man with whom I worked desperately wanted to feel some sort of emotional connection with his father. To all appearances, his father was a good man and a good father, but he was incapable of showing warmth and caring to his son on an emotional level. The son’s drug use was an attempt to self-medicate the pain he felt at the lack of that important connection in his life.

It reached a point where the son called his father and said he had a knife in his hands and was ready to slit his wrists because he was so desperate for his father to show some level of care and concern for him. The father responded; the son did not commit suicide. He told his father of his drug use, and the son agreed to go into recovery. The son had received a message of worthlessness from his father, and he found that message too painful to live with. He forced his father’s hand to show caring.

In recovery, the young man gained an understanding of how deeply he felt the sense of emotional abandonment by his father. Once he gained an understanding of that emotion, he was ready to pursue the fourth step.

4) Change the way you tell your story. For that young man, recovery meant telling his story differently. Instead of telling himself that his father’s coldness meant he was worthless, he came to understand that his father’s coldness was his father’s nature — the product of his father’s own difficult upbringing. The son learned that he was capable of finding the sort of emotional connection he craved with his mother, his siblings, his friends and his new companions in Alcoholics Anonymous (AA).

He came to accept that he would never change his father, but he learned that he could change himself so that he could find the emotional gratification he longed for from others. He had previously believed that he needed to be like his father — cold and emotionless. Once he changed his story and gave himself permission to truly feel the emotions he was experiencing, he could share those feelings with others and find the sort of emotional connections that he craved. Once those emotional longings were satisfied, his need to numb out his more painful emotions evaporated.

Changing one’s story is fundamentally an act of building self-esteem. Self-esteem is built in a number of ways. It comes from allowing oneself to feel one’s emotions, from avoiding all-or-nothing thinking and from recognizing that life events most often consist of shades of gray. Finding the strength to express one’s true self among others, and to experience that self as different from other people and to develop enough detachment to become comfortable with those differences, is also essential.

For some people, and particularly those who had difficulty with their parents while growing up, spirituality may provide the context for seeing themselves differently. This is the concept behind the step in AA to surrender to a higher power, however that higher power may be understood. Seeing oneself as a child of God may provide a corrective lens for those who grew up with the fun-house mirrors and were never able to gain a true picture of themselves through the eyes of their parents.

I once spoke at a Christian-based recovery center where I offered that sort of corrective vision to the patients by slightly changing the word order of a familiar Scripture reading. I told the audience, “If you want to know who you are, consider these words from the Gospel of Matthew. ‘You are blessed, you who are poor in spirit, because yours is the kingdom of heaven. You are blessed who mourn, for you shall be comforted. You are blessed who are meek, for you shall inherit the earth,’” and so on through the remaining Beatitudes. And then I said, “You are a child of God, because why else would Jesus have taught us to pray to God as ‘Our Father?’”

Learning to see oneself differently, and changing one’s story in a way that builds self-esteem, is the fundamental act of recovery. Guiding patients through the growth of creating a healthy sense of self-esteem is at the core of my work as a counselor. People are not only recovering from the habit of substance abuse. They are recovering their lost selves.

Spinoza wrote, “The more clearly you understand yourself and your emotions, the more you become a lover of what is.” Examining emotions with patients and helping them to see themselves as they truly are is the royal road to helping those in recovery. It is the path that leads them to self-knowledge and self-esteem. Ultimately, it is the path out of the trap of human bondage.

 

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James Rose, a national certified counselor and graduate professional counselor, is a recent graduate of Loyola University Maryland and works in addictions treatment at Ashley Addiction Services. Contact him at jrrose@loyola.edu.

 

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Read more by James Rose, from the Counseling Today archives: “Stepping into recovery

 

Related reading, also from Counseling Today: “Grief, loss and substance abuse

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.